Inspection on 23/02/06 for Birwood

This inspection was carried out on 23rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birwood 19/08/09

Birwood 05/08/08

Birwood 19/04/07

Birwood 11/08/05

Birwood 21/01/05

Birwood 15/04/04

Birwood 04/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Birwood Wheathills Road Huyton Knowsley Merseyside L36 5UR Lead Inspector Miss Diane Sharrock Unannounced Inspection 23rd February 2006 12:30 Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Birwood Address Wheathills Road Huyton Knowsley Merseyside L36 5UR 0151-449-3333 0151 449 3333 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.c-i-c.co.uk. Community Integrated Care Mr Ian Campbell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to Include up to 3 (LD) Date of last inspection 11th August 2005 Brief Description of the Service: The home is a 3 bedded bungalow currently registered as a care home for Younger Adults with Learning Disabilities offering “Residential Personal Care”. The Bungalow is situated in Wheathills Road, Huyton close to local amenities. Community Integrated Care is the named company. The Registered Manager is Mr Ian Campbell. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on 23/02/06. A selection of records were reviewed, general discussions with staff took place and one resident and a selection of comment cards were also left. There has been no cause for any visits to the home since its last routine inspection. What the service does well: What has improved since the last inspection? What they could do better: Full feedback was given to staff on duty at the end of this inspection and also to the manager 24/02/06. Out of a sample of some standards reviewed, some areas were noted to need further work and development to enable the standard to be met in full. 1) A maintenance/decorating/refurbishment development plan should be developed to help all parties being included in the development of their home. Moving and Handling training must be provided as a matter of priority for those staff who have not received an update. One care plan whilst detailed it did need to be updated to be specific to the residents needs – one point discussed at the last inspection needs immediate review and action taken by the Company to ensure residents are supported in going out whenever they want to. 2) 3) Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 6 4) Due to current staffing levels the Manager is still not able to work supernumerary to fulfil managerial hours, this should be reviewed by the Company. All personnel files should have the required information set out in the Care Home Regulations and the Company must demonstrate they are storing these records as required to meet these standards. The management of residents’ finances must be reviewed and the Company again are required to have the necessary evidence as set out in the Care Home Regulations to meet these standards. This is a longstanding issue and the Company must demonstrate they are evidencing these standards. A detailed Action Plan must be submitted to CSCI detailing what action they are taking to ensure residents have information about all of their finances including any type of bank account, allowances, mobility etc. CSCI would advise representatives of the Company to arrange a meeting with this office to discuss this outstanding issue. 5) 6) The Responsible Person should submit an Action Plan to CSCI following the inspection to give details of what actions will be taken to meet all requirements made, including those outstanding from the last inspection. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not measured on this occasion. EVIDENCE: As identified at the homes previous inspection, the home has three longstanding residents and there is no change to the current status. At present time, there are no new admissions into the home. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 A review of personal support should still take place so that the residents’ personal choices are not restricted. There continues to be progress made within all care records. EVIDENCE: Individual plans of care are available and have detailed evidence of meeting individual needs and health needs. The “Essential Lifestyle Plans” identify a planned approach to an individuals “likes and dislikes”. One plan was noted to still be in need of updating regarding continence assessments and social support. As identified previously, support for one resident for trips out still needs further review and long-term action taken by the Company to enhance this person’s ability and access to the community. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 16 Family members are kept informed and involved with regular contact. Residents’ rights are respected. EVIDENCE: Staff were observed to have a good rapport with residents and were observed to assist residents in various choices. Resident’s rights, likes, dislikes and choices are respected and responsibilities are recognised. One outstanding issue from the previous inspection was regarding support of one resident in the community. This needs further review and long-term planning by the Company so that steps are taken to enhance this resident’s access to the community. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 The use of ELP’s (Essential Lifestyle Plans) have helped identify individual choices. The homes staff have developed “My Health” documents. EVIDENCE: The above plans were noted to be very detailed and included each person’s likes and dislikes and were noted to be very individualised and specific to residents needs. The “My Health” documents were noted to be detailed and individualised to each residents needs. Continence assessments should be reviewed so they are up to date and reflect the residents present needs. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Staff have had necessary training to help protect residents. One outstanding issue is around the management of residents’ finances. EVIDENCE: Staff on duty stated they had received recent training on ‘Abuse Awareness’ and fell it was a beneficial course for their work. Standard 23 was not measured in full, as records were not accessible during this visit. There is one outstanding issue around the management of residents’ finances. Following this visit the Manager had contacted CSCI. The Company still have access to each resident’s mobility funds and accounts held at head office. The residents have no rationale, record or evidence of what head office are holding on their behalf. The Company must address this issue as a matter of priority and ensure all processes are open, transparent and in line with the Care Homes Regulation 2001 and National Minimum Standards. CSCI so that this outstanding issue is resolved and the Company can evidence they have taken the appropriate action. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not measured on this occasion. EVIDENCE: Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 Staff described recent training and outdated training. Personnel records were not accessible during this inspection. EVIDENCE: Staff described various training sessions they had attended and had recently been to an ‘Abuse Awareness’ course. Staff identified a need for an update in Moving and Handling which must be arranged as a matter of priority to ensure the safety and practise of all parties. Personnel files were not accessible during this inspection as staff explained they are locked away and only accessible by the Manager. The Responsible Persons must demonstrate that these records have the necessary information as required by the Care Home Regulations 2001 and National Minimum Standards. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 The home is well managed by a long-standing manager. Residents have various support to identify their views. EVIDENCE: The manager is now back at the home full time and has been there for many years offering a great stability and rapport to all the residents. At present the manager has not always been able to have managerial hours due to staffing levels, this must be reviewed by the Company. Staff explained how they support each individual with their views, which was acknowledged by one resident. The ELP’s are also good evidence to show residents are assisted in identifying their own likes and dislikes. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 X X X X Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 17 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 20 Requirement For the Responsible Person to provide evidence to CSCI the Manager and Residents, that outstanding monies kept in head office are arranged to be paid into each Residents individual account as a matter of priority and all transactions are open, transparent and in agreement with each resident. For Company Representatives to contact CSCI to arrange a meeting to discuss this outstanding issue. The Responsible Person must ensure that the staffing of the home meets the ongoing needs of the Service Users, and submit evidence to CSCI describing the actions taken to meet this regulation and inform the Residents of actions to be taken to support them both in the community and in their place of work. The Responsible Person must arrange updated training in Moving and Handling. The Responsible Person must demonstrate that all personnel DS0000021516.V284928.R01.S.doc Timescale for action 20/04/06 2. YA6 18 1 a 04/05/06 3. 4. YA32 YA34 13(5), 18 17 20/04/06 04/05/06 Birwood Version 5.1 Page 18 records are stored appropriately with all necessary information. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA42 YA24 YA42 YA19 Good Practice Recommendations To identify and develop Managerial hours for the present Managerial role and demonstrate day to day management of Birwood. To provide an updated written maintenance/decorating/refurbishment programme including dates for replacement of the kitchen flooring. To provide details of plans to improve the accessibility and utility of the garden. To update care plans and update reviews to reflect the current support and care needs, especially one ELP and continence plan. Birwood DS0000021516.V284928.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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